Domestic Violence

I congratulate the Department of Health on its guidance to health care professionals working on domestic violence. Its manual, which is a key resource for health care workers on domestic violence, is a model to be proud of. I welcome the fact that, over the past few years, it has been increasingly recognised by health professionals and the Department that health services play a critical role in providing access to help and protection for abused women and children and are a front-line point of contact for anyone experiencing domestic violence.

Until recently, the health service has tended to disregard all but the immediate medical needs of people experiencing domestic violence. Any refuge relying on the support of GPs and health visitors will confirm that that has been a mixed experience, subject to the resources and understanding of the staff who work with it. Recent initiatives by the royal colleges and the crime reduction programme have undoubtedly improved responses to domestic violence, as has the welcome funding of a Women's Aid programme to raise awareness of the issue.

However, much more remains to be done. Domestic violence is a key issue for the national health service, so why is it not referred to at all in the NHS plan? We need a more systematic approach across front-line health services to training; we also need to enable domestic violence survivors to access safely help that they may desperately need. In particular, we need clear measures to show how health trusts and, more importantly, primary care groups and trusts are implementing the guidance. A recent survey by Women's Aid shows that performance is patchy and the measurement of outcomes almost non-existent. General practitioners, dentists, health visitors, nursing maternity services, psychiatric and mental health care, general medicine, surgery and accident and emergency departments all need to be provided with training and confidence to identify and provide guidance.

Survivors should not have to rely on enlightened health care professionals; they should be sure that help is available wherever and whenever it is needed. Domestic violence, particularly violence against women, is a problem in all countries, whether rich or poor. According to the British Medical Association, in this country it affects about one in four women, regardless of ethnic origin or status. The BMA found that about one in nine women using the health services have been hurt by someone they know or live with. The Department's own 1997 publication, "On the State of the Public Health", acknowledged that
the health and social costs and consequences of domestic violence are extensive and serious enough to constitute a major public health issue.
Research has shown that health care services are often the first point of contact for women living with violent men. Women fleeing domestic violence are most likely to attend accident and emergency departments because of their 24-hour access and the anonymity that they provide.

According to a 1996 study, domestic abuse is a common cause of significant injury, mental health difficulties and chronic health problems in women. It is
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estimated that 50 per cent. of women being treated for mental illness have a history of domestic violence. It has been well documented that psychiatric illness, particularly depression, anxiety and post-traumatic stress disorder, is greater in women who have experienced domestic violence. Many women do not talk about their abuse because of fear or shame. Often, a partner will not let a woman out of his sight, so a visit to a GP, often because of the illness of a child. may be her only way to communicate the problem. She may not know how to seek help, so an appointment at the doctor's or the hospital may be the only time when she is alone and able to talk.

Violence and abuse are a public health scourge and their effects on health and well-being should never be underestimated. Many health professionals see patients whom they suspect of being abused at home, but may be unsure about to how to deal with the issue. That was the depressing finding of a recent Women's Aid report. Health care professionals have to engage with those embroiled in violent situations to deliver the appropriate care. Research has found that, in some cases, health professionals are seeing abused women as many as eight times before action on domestic violence is taken. It can be difficult for someone to acknowledge that the abuse that she is experiencing is domestic violence. That is not helped by professionals who do not recognise the seriousness of the matter.

In the online consultation between parliamentarians and survivors of domestic violence, Womenspeak, one survivor stated:
None of the help I received whilst still married was of any use. I got told that as it wasn't happening every day. I should count myself lucky. I knew nothing about the help I could have received and no one told me. I also did not realise at this stage that the abuse I was receiving was domestic violence. It must have been obvious to the police, solicitor and staff of the hospital but no one said a word.
Recognition of the abuse is often the first step to seeking help, so any agency responding to a domestic violence situation must, at the very least, offer the victim adequate support and supply relevant information about support available in the local area. The Womenspeak consultation found that that rarely happens in some areas.

In another contribution from the consultation, a woman reported:
For six of those years I had no help from the police until I was admitted into hospital. While I was at the hospital I was given no advice on the help I could get, even though the nurse and doctor who treated me knew that I had been attacked by my partner. It was only when a police officer came to take a statement from me the following day that he gave me the number of the Domestic Violence Officer, who in turn gave me the number of a refuge for women. This was the first I knew that there was any help for myself and my son.
Research in 1999 found that women experiencing domestic violence present frequently to health services and require wide-ranging health interventions, so a variety of health professionals have daily contact with patients whose health may be at risk or is already damaged by domestic violence, often over many occasions, yet only 6 per cent. of abused women were accurately identified in emergency departments.

It is an appalling fact that violence against women is more likely during pregnancy and early parenthood. The extent and level of abuse was well illustrated by a midwife who recently confessed that she had little idea about the
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problem until a woman whom she had cared for and whose baby she had delivered just 48 hours before was readmitted for care because her husband had cut away her perinatal sutures in order to have intercourse.

Pregnant women in violent circumstances look to midwives to help them confront the issues and receive support. It is a sad fact that maternal morbidity and pre-natal morbidity and mortality are significantly higher in women who live in violent and disadvantaged circumstances, and the numbers have been increasing. For the first time, domestic violence is included as one of the causes of death in the last maternity mortality report, "Why Women Die".

The recently produced Department of Health midwifery action plan includes a clear steer for midwives towards developing their public health role. It acknowledges the need for midwives to be skilled in recognising the emotional, sexual or the often more evident physical abuse which take place against women, and to be able to act in the best interests of the woman and baby who are the primary focus of midwives' care. Sadly, that is not the norm throughout the national health service. I can cite an example from my constituency, where a GP told a woman who came to him after being set on fire by her husband to go home and not to annoy her husband again.

That approach is reflected in a recent survey by Women's Aid, which found that only 27 per cent. of health authorities had a written practice or protocol for dealing with domestic violence. Fewer than a quarter collect information on the incidence and prevalence of domestic violence, and about half included the issue in their health improvement programme, which might simply mean the inclusion of a sentence on the subject and might not mean much action in practice.

The survey reveals a similar or worse picture of practice among health trusts, yet health care professionals working in trusts are in an ideal position to encourage disclosure of abuse and to record it in order to highlight the scale of the problem and the need for relevant services. The report concludes that most trusts seem to ignore that.

In areas such as mine, there has been a large increase in the reporting of domestic violence, with about 250 incidents reported a month. Increasingly, those reporting are women from ethnic minorities, but as is the case in many trusts, little or no information about domestic violence is available in ethnic languages. Like many primary care trusts, the focus of what training exists is on health visitors alone. In Luton primary care trust health visitors have, in the past, attended training sessions set up by Women's Refuge and have updated training. Like other primary care trusts, it relies on one identified health visitor with experience in domestic violence who is a resource for her colleagues. But what happens when she leaves?

As for general practitioners, once again the picture is pretty desperate for those seeking help with domestic violence. General practitioners do not have formal training, either as junior doctors or as postgraduates. Locally, Luton primary care trust has encouraged GPs to be involved with training undertaken by health visitors, but it is not compulsory. Nationally, less than 9 per cent. of primary care trusts have a domestic violence policy and less than a quarter have a member of staff with some responsibility for domestic violence issues.

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It is clear from the survey that most senior staff in primary care trusts have given the matter relatively little or no thought. Where they have, they have cited difficulties of developing and implementing a policy throughout the various independent GP practices and other primary care services.

Despite the increasing importance of primary care groups and trusts as the front line of resources and contact for survivors, the picture does not look good. Many respondents felt that the only way to effect change was for domestic violence to become one of the designated priority care groups and have their performance measured.

As one health authority acknowledged:
Domestic violence is not properly recognised as a priority. It is very difficult to raise any form of interest except in a small minority of already committed and interested informed people.
Another primary care group said:
Having read the questionnaire it is apparent that the vast majority of issues covered do not apply to the services we commission nor has the topic been identified as a priority for the primary care group.
What hope, then, for the woman who seeks help from her GP? She may find little or no literature or training, and little or no network to point her towards support and assistance.

Worryingly, there is still no systematic monitoring of the extent to which women experiencing domestic violence make use of the health service, nor of the outcomes when they do, and very few health authorities collect their own data on incidents or referrals.

Responding to domestic violence is the responsibility of all agencies, not just the police or Women's Aid. The health service has a pivotal role to play in the identification, assessment and responses to domestic violence, not only because of the impact and cost of domestic violence to women's health, but because of the cost to the health service itself. For example, the financial cost of domestic violence for health agencies in Hackney in 1996 was estimated at £580,000, and that did not include hospitalisation and medicine.

It is essential that health professionals are sensitive to signs and indicators that might suggest domestic violence. Women may find it hard to make the first step by disclosing domestic violence, but they may hope that the health professional will notice that something is wrong and put them in touch with support.

What can the NHS do? I urge the Minister to take action on reinforcing the guidelines, particularly to primary care groups and trusts where their involvement is so vital. We need systems which monitor how or whether the guidelines are being used throughout the health service, but especially among front-line provision such as GPs and accident and emergency services.

We need training on domestic violence issues to be included within the initial professional education of all health care staff and as a regular part of on-going training. For the national health service effectively to respond to the needs of those experiencing domestic violence it needs to ensure that it is raising awareness among staff of domestic violence and its effects; to instigate compulsory training; to create a safe environment which encourages disclosure by those experiencing domestic violence; to develop safe protocols for helping those in this situation; to develop good referral systems as part of a multi-agency response; to ensure that women health professionals are
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available where necessary; to seek to empower those experiencing domestic violence to make their own informed decisions; to provide options and information; and to respect confidentiality. It needs to display information and to work with refuges, helplines and outreach and advocacy services for women and children, and also to develop referral and support networks recognising the role and skills of other agencies.

It is clear that, unless responses to domestic violence are included among the criteria against which the performance of health care providers is measured, many will continue to ignore the issue. The health service may be a lifeline for women whose contact with the outside world is restricted by a violent partner. For them, access to front-line health services that recognise and respond to their needs may be a matter of life and death.

I am delighted to congratulate my hon. Friend the Member for Luton, South (Margaret Moran) on securing this very important debate. I am aware of her tremendous record of raising these issues in the House in relation to almost every single Department. By her personal endeavours, she has raised the matter way up the agenda. I am also personally aware of the online consultation that she was responsible for organising, which gave women the opportunity to respond through the internet and to tell their own stories about their experience of domestic violence. There is nothing more moving than to read and understand the real experiences of women in the community and the impact of domestic violence not on only them, but on their families. I commend that consultation to all hon. Members who have not had the opportunity to hear and understand the views that have been expressed, which are extremely powerful and have been a great aid to us all in understanding the complexity of some of the issues that are involved.

The facts about domestic violence are shocking to all of us. About one in four women will experience domestic violence at some time in their lives. Although we have heard predominantly about women in this debate, there is a clear recognition that domestic violence sometimes involves men as its victims, and we must not forget that. More than 1 million incidents of domestic violence are recorded by the police every year. One in four of all assaults involve such violence. Two in every five women who are murdered are killed by a partner or ex-partner. Certainly, domestic violence is very rarely a one-off episode. More often, the experience is one of repeated and intensifying assault. On average, a woman experiences 35 incidents of domestic violence before seeking help. That is the extent of the problem.

About a third of domestic violence starts in pregnancy. Often, when there is domestic violence in a family, it escalates during pregnancy, when women are at their most vulnerable. Women with unwanted pregnancies often carry the greatest risk. Domestic violence is clearly associated with miscarriages, premature birth and labour. low birth weight, and foetal injury and death.

Almost all women will have contact with the health service by being registered with a GP. I agree entirely with my hon. Friend that the health service is ideally
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placed to pick up and monitor cases and, it is to be hoped, to take action in this very important area. A recent study showed that approximately 80 per cent. of women in a violent relationship had sought help from the health service on at least one occasion.

The issue is one for the Government as a whole and not just the NHS. The policy document "Living Without Fear", published in 1999, set out the Government's initiatives across all Departments, as well as good practice and our commitment to tackling domestic violence and other forms of violence against women. It is important that we consider not only the women who are involved, but the children, who can suffer if they live in households where there is regular domestic violence. It has been shown that such violence can have a serious impact on children's development and well-being.

The health service has a particular role to play in trying to counter domestic violence. Health professionals are most likely, out of those in all agencies, to come into contact with its victims. They are also the most likely people to be perceived as non-judgmental, which is a very important issue for women in these circumstances. Many women simply want the abuse to end, but they may be concerned that their children will be taken away from them once the agencies start to intervene. There is a genuine fear that, once social services become involved, the consequences can sometimes be dire for the whole family. Women's trust in health professionals whom they do not see as threatening or judgmental can therefore be vital in giving them the self-confidence to disclose what has been going on.

Health professionals have a key role to play in helping women to tell them what is happening in their homes, in providing support and practical advice about the available options, which is what many women are looking for, and in demonstrating a continuing understanding and a source of help or referral. Whatever decision the woman initially makes, the health service professional will be there to support her, to help her through the system and to help her to take advantage of the choices on offer.

My hon. Friend referred to the NHS resource manual for health professionals that was developed in March last year. I am grateful that she thinks that it is a valuable resource. The manual builds on and consolidates guidelines that have been issued by the various royal colleges. It provides greater clarity to stimulate the debate and to inform the development of good practice throughout the health service. It is aimed primarily at health care professionals, to try to increase their knowledge and understanding of the issues, to highlight the nature of domestic violence that takes place in a range of settings, and to show how it is likely to be evident among the patients for whom they care. They will then be able to see the warning signs and the symptoms, and be ready to intervene and to take action.

The manual is to be used as a resource that provides a starting point for health authorities and trusts to review their own policies and practices. I accept that it needs to be supplemented with information and data that will support local implementation, because the manual will only be good when it is keyed into what is happening in local communities and used as a source of practical help on the ground, providing real information to assist people.

It is essential that front-line workers be supported by their managers in implementing and developing the protocols to tackle domestic violence. There needs to be
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better monitoring and much more extensive information gathering, so that we can be aware of the full extent of the problem. My hon. Friend is right to say that if we can measure progress, things tend to get done. Unless we do so, this issue could slip down the agenda, which is certainly not what we want.

The resource manual has been widely taken up, right across the health service. The first print run of 10,000 copies has already gone, and the second print run is going well. We are trying to push it out into every part of the NHS.

We are also moving on from there. We are funding the Women's Aid Federation of England in a three-year project to raise awareness of domestic violence in the health service. The federation carried out an initial survey, the findings of which were published last year, as my hon. Friend mentioned. She is right to say that not enough health authorities or trusts have their own written policies, or an accurate way of monitoring the extent of the problem in their communities. We at the centre need to ensure that, as the primary care trusts begin to develop their commissioning policies, they take this matter seriously. The federation's survey has been tremendously useful in showing us what action is being taken on the ground, where the gaps are, and where we need to do even more.

The Women's Aid Federation will undertake a second survey next year to gauge how successful the manual and its awareness project have been. We intend to measure and monitor these processes and to ensure that they happen. The federation has also published a practice directory, a very useful document giving examples of new health care initiatives in tackling domestic violence. One of the challenges for the NHS is to try to spread good practice. There are pockets of excellence everywhere in this country. and it is sometimes frustrating that we try to reinvent the wheel rather than learn from each other and spread the good ideas across the country. The directory of good practice will be a useful tool for the whole NHS to use.

We have also considered domestic violence in relation to NHS Direct. If women telephone the service, they can get immediate advice, signposting and referral to appropriate support services in their community. The telephone number of NHS Direct is becoming much more widely known, and the service has now been rolled out nationally. In the east midlands, NHS Direct has been piloting a domestic violence protocol for use with callers to the service. It will report on the pilot, and if it is successful it will be rolled out to other areas of the country.

Although tackling domestic violence is important to the NHS, it is also important for us to respond to these problems on a cross-government, multi-agency basis. The Home Office has been active in supporting a whole range of initiatives under the crime reduction process. I want to highlight two examples in which the health service, eduction services and local authorities have been able to do really practical work in tackling these issues. The first is in north Devon and Torridge, which is a rural area. Often, support services for women suffering from domestic violence are particularly difficult to access in
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such areas, because they are concentrated in urban communities. The project provides services in the local accident and emergency department, which is where many women immediately go when they experience domestic violence.

It is hoped that the project will expand in its second phase to encompass every health centre and doctor's surgery in the district and two small local hospitals. It aims to provide advice from Women's Aid and legal advice from solicitors and to ensure that 24-hour victim support is available on the spot to help women—and, indeed, men if they are victims of domestic violence—through the health service. We can all learn from the project, and we should evaluate it to judge how successful it is. We must ensure that there is support in the community to help people in that situation, whatever the time of day or night. The project is extremely interesting.

The other example I want to highlight is supported by the health action zone project in Leeds. It is entirely different, but just as valuable. Three local schools and a mixed-sex group of boys and girls aged eight and nine are involved. The aim is to ensure that they are aware of the problems of domestic violence from a very early age, to extend awareness and to ensure that domestic violence is on their agenda.

I hope that, when we raise the next generation, we will not duplicate the problems that exist in so many families. Again, a multi-agency approach is involved—raising awareness and ensuring that we can support those young people if they happen to be in families where domestic violence unfortunately occurs, as well as giving them the self-confidence and self-esteem to tackle it themselves.

Those are two of about 22 projects being funded this year. There were 200 bids for support from a £10.7 million programme, which is making a tremendous impact on tackling domestic violence in communities. There is a great deal going on, but I would not claim to my hon. Friend the Member for Luton, South that we do not have a lot more to do on the issue. It is widespread and it infiltrates so many families in our community.

All Members of the House want to ensure that we send a clear message that there is never any excuse for domestic violence. It is a crime like any other. It turns people's lives into tragedies for themselves, their children and the rest of us. The Government have to put practical support in place so that we give people choices. Domestic violence is dreadful, because it traps many women and victims generally in a situation in which they feel there is no hope and nobody there to help. There is nobody they can turn to, and they are isolated and alone.

We must ensure that we put in place in our community support networks that give people the chance to live the kind of life that almost all of us take for granted. We are making progress, but we have a long way to go. I am delighted that my hon. Friend has again raised the issue in the House and ensured that we all have it at the forefront of our minds when we develop policy in this extremely important area. I congratulate her again on raising it in the debate.